Factors influencing COVID-19 vaccination decision-making among African American and Hispanic pregnant and postpartum women in Deep South

Background COVID-19 vaccination is vital for ending the pandemic but concerns about its safety among pregnant and postpartum women, especially among African American (AA) and Hispanic women, persist. This study aims to explore factors that influence vaccination decision-making among AA and Hispanic pregnant and postpartum women through women’s experiences and maternal care providers’ (MCPs) observations. Methods From January and August 2022, we conducted semi-structured interviews with AA and Hispanic women and MCPs. Participants were recruited from obstetric and pediatric clinics in South Carolina, and all births took place after March 2020. Thematic analysis was employed for data analysis. Results The study involved 19 AA and 20 Hispanic women, along with 9 MCPs, and revealed both barriers and facilitators to COVID-19 vaccination. The factors that influence pregnant and postpartum women’s decision about COVID-19 vaccine uptake included: 1) awareness of health threats associated with COVID-19 vaccines, 2) vaccine availability and accessibility, 3) vaccine-related knowledge and exposure to misinformation, 4) concerns regarding pre-existing health conditions and potential side effects of COVID-19 vaccines, 5) emotional factors associated with vaccination decision-making processes, 6) concerns about the well-being of infants, 7) cultural perspectives, and 8) encouragement by trusted supporters. Conclusion Findings suggest that reliable information, social support, and trusted doctors’ advice can motivate COVID-19 vaccination. However, barriers such as misinformation, mistrust in the health care system, and fears related to potential side effects impede vaccination uptake among AA and Hispanic pregnant and postpartum women. Future interventions should target these barriers, along with health disparities, involve trusted doctors in outreach, and initiate vaccine conversations to promote vaccination among this population.


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The COVID-19 pandemic has caused a significant number of cases and deaths worldwide, National Immunization Survey (COVID-19 supplemental module) showed that among women aged 18-46 49 years, COVID-19 vaccination coverage was lower among pregnant women (45%) and breastfeeding women (51%) than non-pregnant women (65%) (3). This is concerning, as pregnant women have a higher 48 risk of severe illness and mortality from COVID-19 and are at risk for adverse pregnancy outcomes, such 49 as preterm delivery and stillbirth, compared with non-pregnant women (4, 5). These disparities highlight 50 the need to investigate the factors influencing COVID-19 vaccination decision-making among pregnant 51 women.

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The decision-making process for COVID-19 vaccination is influenced by various factors,

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including limited available safety data on COVID-19 vaccine during pregnancy, lack of confidence in the 54 safety and efficacy of the vaccine among health care providers and pregnant women, issues related to 55 vaccine prioritization, access, and availability, as well as cultural and language barriers (3, 6, 7).

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Moreover, pregnant women are particularly concerned about the potential safety issues for their children 57 associated with COVID-19 vaccination, which stems from the limited data on the effects of the vaccine 58 on fetal development (8). These unresolved concerns about the safety and efficacy of the COVID-19 59 vaccine can lead to hesitancy in their decision-making process. The research on COVID-19 vaccination 60 during pregnancy has significantly expanded (9, 10). However, the presence of inconsistent information 61 from social media and health authorities during the launch and promotion phases of the vaccine, coupled 62 with conflicting advice from medical and public health professionals, has led to confusion and the 63 perpetuation of misinformation (11,12).
116 worked in clinics that primarily served AA patients (50-80%), and three MCPs worked in clinics that 117 served more evenly mixed patient populations (both AA and Hispanic patients comprised 20-40%) ( Table   118 1).

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Based on AA and Hispanic women's experiences and MCPs' observations, the current study 121 revealed several factors that influenced the women's decision-making regarding COVID-19 vaccination 122 with the following key themes emerged: 1) awareness of health threats associated with 2) 123 vaccine availability and accessibility, 3) vaccine-related knowledge and exposure to misinformation, 4) 124 concerns regarding pre-existing health conditions and potential side effects of 5) 125 emotional factors associated with vaccination decision-making processes, 6) concerns about the well-126 being of infants, 7) cultural perspectives, and 8) encouragement by trusted supporters. 139 "I was afraid to get sick especially at the beginning of the pandemic." (Hispanic 5)

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The news coverage of pregnant women experiencing severe outcomes from COVID-19 141 contributed to their anxiety. Participants were particularly concerned about the potential risks to their own . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 24, 2023. ;https://doi.org/10.1101https://doi.org/10. /2023 health and the health of their infants. They expressed fear of getting sick and the possibility of adverse

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Participants expressed concern about their ability to control the exposure of their children to the 157 virus and the potential consequences of attending prenatal appointments. They highlighted their efforts to 158 maintain a safe home environment and limit exposure to individuals entering and leaving their 159 households. The anxiety and nervousness experienced by the participants led to heightened precautions 160 such as frequent handwashing and avoidance of crowded places. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023.  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023.  is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023. ;https://doi.org/10.1101https://doi.org/10. /2023 398 through initiatives such as mobile vaccination clinics, community outreach programs, and targeted 399 scheduling systems can help alleviate the challenges expressed by participants and contribute to increased

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Participants also raised concerns about potential side effects and the desire to observe long-term safety  is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 24, 2023. were all immigrants, which may limit the generalization of the finds to Hispanic mothers with different . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 24, 2023. ; https://doi.org/10.1101/2023.07.20.23292951 doi: medRxiv preprint background. Third, we did not recruit white women in this study; thus, we cannot direct compare the 451 experiences of different racial and ethnic groups in vaccination decision-making. Future studies should 452 consider diverse samples to further explore these factors and develop targeted interventions to improve 453 vaccine acceptance in these populations. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 24, 2023. ; https://doi.org/10. 1101/2023  is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 24, 2023. ; https://doi.org/10. 1101/2023